Provider Demographics
NPI:1790181857
Name:MITCHELL, JONATHAN (PA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 TROY DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7661
Mailing Address - Country:US
Mailing Address - Phone:910-762-2727
Mailing Address - Fax:910-762-7923
Practice Address - Street 1:110 S 20TH ST STE 4
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-4486
Practice Address - Country:US
Practice Address - Phone:215-558-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant